Impact of critical care pharmacist‐led interventions on pain, agitation, and delirium in mechanically ventilated adults: A systematic review

Abstract

Best practices of pain, agitation, and delirium (PAD) management require coordinated, bundled care among an interprofessional intensive care unit (ICU) team. Clinical pharmacists are essential health care team members in optimizing sedation and analgesia management in critically ill patients. The purpose of this systematic review is to summarize the clinical impact of pharmacist‐led interventions targeting PAD in mechanically ventilated adult ICU patients. A literature search was conducted using MEDLINE, EMBASE, CINAHL, SCOPUS, and the Cochrane Central Register of Controlled Trials between January 1, 2000 and September 1, 2022. Randomized controlled trials, quasi‐experimental, or observational studies comparing pharmacist‐led interventions aimed at PAD management best practices and usual care in adult (≥18 years) ICU patients were included. Clinical (mechanical ventilation duration, hospital length of stay, and mortality) and economic outcomes as well as sedation and analgesia utilization were evaluated. A total of 1418 citations were identified with 9 studies (n = 3769 patients) meeting eligibility. The types of pharmacist‐led intervention strategies were inconsistent among included studies. Four of the 9 studies showed that pharmacist‐led interventions were associated with a significant reduction in mechanical ventilation duration ranging from 4.0 to 8.5 days compared with approximately 5.6 to 14.0 days in the control groups. Three (50%) of 6 studies evaluating length of stay showed significant reductions with the intervention group compared with controls. No impact on mortality and ICU‐acquired delirium/coma rates was shown. The pharmacist‐led intervention group was also associated with significant reductions in opioid analgesia and sedative utilization. Only two studies evaluated the financial impact of the intervention group with one study finding a positive benefit attributed to decreased drug utilization, while the other report failed to find an impact on total hospital stay costs. Pharmacist‐led interventions promote PAD best practices in the ICU, although the impact on patient‐centered outcomes remains controversial.

Critical care pharmacists have a rich history and evolving roles

“…Evidence-based pain, agitation, and delirium (PAD) guidelines and the ICU liberation bundle are well-established tools for optimal PAD practices, and pharmacists have led implementation efforts. 16,17,35,36 Barriers early in COVID-19 included drug shortages, staffing shortages, avoidance of bedside care and patient assessment, and overall uncertainty regarding optimal management. This unique scenario challenged best practices and caused regression in care.…”

“…Currently, it takes well over a decade for broad adoption of guidelines but regression to prior habits may be rapid as shown during the pandemic. Evidence‐based pain, agitation, and delirium (PAD) guidelines and the ICU liberation bundle are well‐established tools for optimal PAD practices, and pharmacists have led implementation efforts 16,17,35,36 . Barriers early in COVID‐19 included drug shortages, staffing shortages, avoidance of bedside care and patient assessment, and overall uncertainty regarding optimal management.…”

Continuing excellence in critical care pharmacy practice, education, and advocacy

“…Critical care pharmacist participation on the multidisciplinary team has also demonstrated considerable benefits in areas such as anticoagulation, 9,10 antimicrobial therapy, 11 pain, agitation and sleep management, 12–14 and overall medication safety 15 . The ICU Liberation Campaign represents bundled interventions conducted by an interdisciplinary team, including a critical care pharmacist that has been associated with improvement in survival, ICU length of stay, and ICU readmission 16 .…”

“…Interpreting complicated pharmacokinetics/pharmacodynamics using advanced therapeutic drug monitoring, 5 evaluation of patient clinical status and organ function, 6 or the ordering and utilization of procedures or laboratory assays to provide optimal pharmacotherapy are now common practice for most critical care pharmacists. 7,8 Critical care pharmacist participation on the multidisciplinary team has also demonstrated considerable benefits in areas such as anticoagulation, 9,10 antimicrobial therapy, 11 pain, agitation and sleep management, [12][13][14] and overall medication safety. 15 The ICU Liberation Campaign represents bundled interventions conducted by an interdisciplinary team, including a critical care pharmacist that has been associated with improvement in survival, ICU length of stay, and ICU readmission.…”

“…15 The ICU Liberation Campaign represents bundled interventions conducted by an interdisciplinary team, including a critical care pharmacist that has been associated with improvement in survival, ICU length of stay, and ICU readmission. 16 The systematic review by Buckley et al 12 describes how pharmacist-led interventions in regards to pain, agitation, and delirium management were associated with a decrease time on mechanical ventilation and length of stay, as well as reductions in opioid analgesia and sedative use. 12 There is also consistent evidence describing the benefits of pharmacists on anticoagulation-related outcomes while reducing costs.…”